Provider Demographics
NPI:1043820376
Name:GONZALES, JAN KENNETH (FNP-C)
Entity Type:Individual
Prefix:
First Name:JAN KENNETH
Middle Name:
Last Name:GONZALES
Suffix:
Gender:M
Credentials:FNP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4245 METRON DR
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32216-1012
Mailing Address - Country:US
Mailing Address - Phone:386-438-4142
Mailing Address - Fax:
Practice Address - Street 1:4251 NW AMERICAN LN
Practice Address - Street 2:
Practice Address - City:LAKE CITY
Practice Address - State:FL
Practice Address - Zip Code:32055-8844
Practice Address - Country:US
Practice Address - Phone:386-758-6143
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-08-02
Last Update Date:2020-08-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLAPRN11008439363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner